Plastic & Reconstructive Surgery:
Kosins, Aaron M. M.D., M.B.A.; Kohan, Emil B.S.; Shajan, Josh M.B.A.; Jaffurs, Daniel M.D.; Wirth, Garrett M.D.; Paydar, Keyianoosh M.D.
Aesthetic and Plastic Surgery Institute; University of California–Irvine Medical Center; Orange, Calif.
Correspondence to Dr. Kosins; 200 South Manchester, Suite 650; Orange, Calif. 92868; firstname.lastname@example.org
Medial canthal tendon rupture results in canthal dystopia, increased intercanthal distance, and loss of palpebral angle.1 Prevailing tendon reinsertion methods include transnasal wires and screws but have been reported to have a high failure rate, and are often complicated by medial canthal drift, wire extrusion, and contralateral orbital bone fracture under transnasal wire pressure.1,2
We present a case of complex naso-orbitoethmoid fracture including avulsed medial canthal tendon treated with open reduction and internal fixation complicated by telecanthus and enophthalmos. Angular restoration of the palpebral fissure and improved eye aperture width and intercanthal distance was accomplished with soft-tissue fixation using the Mitek anchor system in medial canthopexy (a recent trend) during revision surgery.
A 17-year-old girl involved in a motor vehicle accident underwent open treatment and fixation of her multiple facial fractures through a coronal incision. Her naso-orbitoethmoid fracture was treated with a titanium mesh plate for her orbital fractures, transnasal wire fixation for a floating medial canthal bone segment, and rigid fixation of the surrounding bones.
The patient's postoperative course was complicated by telecanthus and decreased left eye aperture distance. Fifteen months postoperatively, we performed a periorbital osteotomy and removed the transnasal wires, resulting in a 3- to 4-mm medial migration of the soft tissue and medial canthal segment. This medial canthal segment was rigidly fixed into the nasomaxillary process using a 3-0 Ethibond Mitek screw.
Evaluation 4 weeks postoperatively after the placement of the Mitek anchor system demonstrated improvement of the position of the medial and lateral canthi, symmetry, and enophthalmos. Postoperative outcomes were assessed using digital photographs (Fig. 1). Measurements confirmed the aesthetic outcome of postoperative physician assessments (Table 1). After the revision operation using the Mitek anchor system and left orbital floor fixation, the patient experienced improvement in intercanthal distance (39.2 to 38.6 mm) and significant improvement in left eye aperture width (18.5 to 23.2 mm, or 25.4 percent increase). Measurements, however, may be affected by eyelid position, direction of gaze, and enophthalmos improvement.
Medial canthopexy addresses traumatic telecanthus and loss of palpebral angle through canthal tendon mobilization, subperiosteal exposure of the central segment of the medial orbit, and fixation to its bony attachment.1 The most effective results are obtained by maintaining or resecuring the canthal tendon whenever possible to its original bony attachment and then displacing the bone to restore proper canthal position.3
Use of the novel Mitek anchor system has been shown to be a viable alternative for medial canthal tendon fixation.4,5 The normal medial canthal tendon is stronger than traditionally thought, withstanding forces of up 36 N before rupture. This strength is most closely approximated by the Mitek anchor system, at 97 percent of normal holding strength as compared with transnasal wires (74 percent) and 1.7-mm screw fixation into the medial orbit (92 percent).2 The Mitek anchor system has been shown to offer considerably reduced perioperative time as a result of increased placement accuracy and greater procedural simplicity; installation of the Mitek anchor is also associated with a smaller external incision (3-mm), minimal dissection, and overall reduced invasiveness.5
The authors have no financial interest to declare in relation to the content of this article.
Aaron M. Kosins, M.D., M.B.A.
Emil Kohan, B.S.
Josh Shajan, M.B.A.
Daniel Jaffurs, M.D.
Garrett Wirth, M.D.
Keyianoosh Paydar, M.D.
Aesthetic and Plastic Surgery Institute
University of California–Irvine Medical Center
1.Kelly CP, Cohen AJ, Yavuzer R, Moreira-Gonzalez A, Jackson IT. Medial canthopexy: A proven technique. Ophthal Plast Reconstr Surg
2.Dagum AB, Antonyshyn O, Hearn T. Medial canthopexy: An experimental and biomechanical study. Ann Plast Surg
3.Goldenberg DC, Bastos EO, Alonso N, Friedhofer H, Ferreira MC. The role of micro-anchor devices in medial canthopexy. Ann Plast Surg
4.Antonyshyn OM, Weinberg MJ, Dagum AB. Use of a new anchoring device for tendon reinsertion in medial canthopexy. Plast Reconstr Surg
5.Okazaki M, Akizuki T, Ohmori K. Medial canthoplasty with the Mitek Anchor System. Ann Plast Surg
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